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APPLICATION FOR PERMIT cir• TM -.. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA c ,, Telephone (209) 456-6781 n�"�'Zk1A PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,�_L.� . (Complete in Triplicate) _ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein escribed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address T� 1✓ �r ge) City Lot Size PM Owner's Name „-+ �� Address Phone Contractor LV C� 496dAddress License No. Z_-7qJN&a Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"1 Public I-1 Other ❑ Delta Depth of-Grout Seal Type of Grout I 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION kP4,No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _ Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or used agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pe, e on" ch manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the fo awi ertif at in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of fo 'a.' The applicant iced inspections. Complete drawing on reverse side. Signed X Title: _o Date: :�7 OR DEPARTMENT USE ONLY �} Application Accepted by Plith Date 1 ��— Area r/ Pit or Grout Inspection by Date Final Inspection bye✓ �'CG� Date Additional Cam t . B ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 935-6395 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED �K R RECEIVED BY DATE PERMIT[NCO. EH 13-24(REV.i/n 5) ,-- , tJ EH 14-214-26